Indications and clinical results of Non-Operative management of periprosthetic hip fractures in elderly patients

Background

The increase in life expectancy in the general population has led to a rise in the use of hip arthroplasties and consequently, to an increase in the incidence of periprosthetic hip fractures (PPHF). The impact of this type of fracture on patients necessitates a personalized approach to treatment, whether surgical or non-operative, taking into account the trajectory and associated comorbidities.

Methods

We performed a retrospective study of 80 patients over the age of 70 diagnosed with a periprosthetic hip fracture between 2011 and 2018. These cases were reviewed after a minimum follow-up of 5 years. We included demographic data, comorbidities including Charlson comorbidity index (CCI), primary prosthesis characteristics, fracture type according to the Vancouver classification, treatment received and mortality among others. Radiographs were analyzed during follow-up and Merle D'Aubigné and visual analog scales were performed.

Results

Fifty-two of the 80 fractures analyzed involved total hip arthroplasties, 26 were hemiartroplasties and only 2 were revision prostheses. A total of 77.5 % had cementless stems and 88.8 % of the patients had significant comorbidities. There were 29 B1 (36.3 %) and 30 B2 (37.5 %) fractures which compromised most of the study cohort. Fifty-three patients underwent surgery compared to 27 patients (34 %) treated non-operatively; most of the latter had short, oblique undisplaced B1 fractures. 28 fractures (35 %) required reduction and fixation (ORIF) while 25 patients (31.3 %) underwent a revision arthroplasty (RA). The mean score at 3 months for the VAS scale was 2.9 points and for Merle D'Aubigné scale, the scores were 4.3 points for pain, 4.1 for mobility and 3.8 for ambulation. Seven patients who underwent surgery died in the first 2 months compared to 2 in the non-operative group. Revision arthroplasty had the highest prevalence of mortality (p=0.032) as did those with a CCI ≥ 6 (p=0.038).

Conclusions

In some low functional demand elderly patients with significant comorbidities non-operative treatment can be considered, especially in fractures with short transverse and oblique patterns where it provides similar clinical and radiographic results to surgical treatment whilst avoiding additional risks in these fragile and vulnerable patients.

Level of Evidence

Therapeutic Level IV (Case Series)